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Intranasal Application of Topical Anesthetic

Posted July 30, 2015

Blue Cross and Blue Shield of Illinois (BCBSIL) Medical Policy MED205.039, or Topical Application Device for Anesthetic Treatment to the Sphenopalatine Ganglion for Headaches (treatment of headache or facial pain) will become effective for dates of service on or after Nov. 1, 2015.

The medical policy states that topical application of anesthetic (including, but not limited to Marcaine or Naropin), with or without steroid(s), to the sphenopalatine ganglion as a nerve block for headaches or facial pain using an applicator for nasal spray or any other similar device,is considered experimental, investigational and, as such, is not a covered benefit.

There is no Current Procedural Terminology (CPT®) code that specifically describes intranasal application of a topical anesthetic for the treatment of headache or facial pain. Per the American Medical Association (AMA), providers are instructed to use CPT code 64999 (unlisted procedure, nervous system) to identify this type of treatment, which, as noted above, is not a covered benefit for BCBSIL members.

To view the BCBSIL Pending Medical Policy for Topical Application Device for Anesthetic Treatment to the Sphenopalatine Ganglion for Headaches, refer to the Medical Policy section and select the Active and Pending Medical Policies link. Pending policies are listed alphabetically – select the title of the policy you wish to view to open the document.

While medical policies may be used as a guide, HMO providers should refer to the HMO Scope of Benefits in the BCBSIL Provider Manual.

Third party brand names are the property of their respective owners.

CPT copyright 2014 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

The BCBSIL Medical Policies are for informational purposes only and are not a replacement for the independent medical judgment of physicians. Physicians are to exercise their own clinical judgment based on each individual patient’s health care needs. The fact that a service or treatment is described in a medical policy is not a guarantee that the service or treatment is a covered benefit under a health benefit plan. Members should refer to their certificate of coverage or summary plan description for more complete details regarding what services are covered including, benefits, limitations and exclusions. Some benefit plans administered by BCBSIL, such as some self-funded employer plans or governmental plans, may not utilize BCBSIL Medical Policy. Members should contact the customer service number listed on the back of their identification card for more specific benefit information.